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Study: Worse health, better care in public housing

Residents in Boston’s government-subsidized housing report having poorer health—but as good or better access to health care—than the city’s overall population, according to a groundbreaking research study.

The study, published in the January issue of the “American Journal of Public Health,” may be the first to report on the health of public housing residents and compare it to that of the city’s overall population.

The study just collected information. It didn’t try to figure out why there is a big difference in health quality.

The study relied on people self-reporting their conditions. That method has some flaws. But, the study’s authors say, the method produces good basic information and is an easy way to make regular reports on the health of public housing residents.

“Survey findings such as these are a good starting point for discussion of health concerns with public housing community members,” the study said. “This information can also inform the design of health services for residents of public housing and is useful in following trends over time.”

“Use of a Population-Based Survey to Describe the Health of Boston Public Housing Residents” was produced by researchers at the Partners in Health and Housing Prevention Research Center at Boston University’s School of Public Health. The center’s other partners include the Boston Housing Authority, the Boston Public Health Commission and the Community Committee for Health Promotion.

“Public housing” includes government-created housing developments such as Jamaica Plain’s Bromley-Heath and people who use government-subsidized vouchers to rent from private landlords. At least 10 percent of Bostonians live in public housing.

Compared to other Boston residents, public housing residents were more likely to report suffering from various health problems: asthma, obesity, heavy tooth loss, depression. They were also more likely to have been diagnosed with high blood pressure and diabetes. And they were less likely to be “physically active.”

Public housing residents were much more likely to smoke than other Bostonians. But they reported less binge drinking of booze and less past-year marijuana use. Public housing residents and other Boston residents reported similar rates of using harder drugs like cocaine.

Despite being sicker than other Boston residents, public housing residents reported good access to health care, and more use of it. They reported having health insurance and health care access at about the same rate as other Bostonians.

And compared to low-income residents in private housing, public housing residents were much more likely to have health insurance and health care access.

The study’s data was collected before the state’s mandatory health insurance law took effect.

Compared to other Bostonians, public housing residents were at least as likely to get regular health tests such as mammograms or cholesterol screenings. But they were much less likely to get dental care.

The study’s method did not include a way to figure out why public housing residents are sicker and have better health care access. But the study’s authors made some educated guesses.

Public housing residents are more likely to be low-income and to identify as a racial or ethnic minority. Many other studies have shown that both of those factors correlate with poor health in the US.

The study did collect some general demographic data that illustrate these differences. Compared to other Bostonians, public housing residents were more likely to be immigrants (though the majority are US-born); more likely to be unemployed; and less likely to have a high school or college diploma. The median income for public housing residents was under $20,000 a year—less than half the citywide figure.

Some public housing is set aside for people with disabilities, many of whom suffer illness by definition. But the study’s statistical analysis showed that the significant difference in health quality rates was not just because of residents with disabilities.

Economics and the health care system might explain why public housing residents had better access to health care.

Public housing residents are more likely to have children and to have low incomes—two situations that can qualify people for subsidized health insurance. Government-subsidized housing may also give residents a bigger portion of household income to spend on health care.

The study found that a higher percentage of public housing residents were women compared to Boston’s overall population. The study didn’t mention it, but recent news reports have suggested that women are more likely to access health care than men.

Public housing developments often feature health care programs and information, which likely boost access. Also, Boston’s strong system of community health centers include several locations near public housing developments, such as the Martha Eliot Health Center next to Bromley-Heath.

Sickness and health care access may also be tied together. Public housing residents are more likely to suffer chronic illnesses. If they have to go the doctor regularly, that may make them more likely to get standard health tests like cholesterol screenings. Just being inside a doctor’s office naturally boosts a person’s access to health information and care.

The study compared raw data, but it also adjusted for known factors that could throw things out of whack. That includes, for example, the amount of housing set aside for residents with disabilities.

The study is scientific, but it comes with some qualifications.

The information was collected by a telephone survey of about 400 residents 18 or older, using a system that dialed random phone numbers. It could only call land-line phones, not cell phones. So anyone who uses only cell phones would be missed.

The information was self-reported by residents. Like all self-reported information, it is subject to biases. For example, people tend to over-report conditions perceived as good and under-report conditions perceived as bad. The study noted in particular that drug use can violate a public housing lease, so it may be especially under-reported in this survey.

All that being said, telephone surveys are an accepted data-gathering method. This study’s method matches that of a similar health survey conducted every two years by the Boston Public Health Commission. That city survey is where the data came from to compare with public housing residents.

The study was accepted for publication a year ago, so its information is not up-to-the-minute. In particular, it was collected before the state’s mandatory health insurance law took effect. On the other hand, the study may inform predictions about that law. It appears that higher rates of health insurance coverage do not automatically mean better health.

The study’s authors were Eleni Digenis-Bury, Leslie Chen and Mary Ostrem, who belonged to the Boston Public Health Commission at the time; and Daniel Brooks and C. Robert Horsburgh of BU’s School of Public Health.